EXERCISE IN THE PATIENT WITH CLAUDI...

EXERCISE IN THE PATIENT WITH CLAUDICATION PAIN

Background

Atherosclerosis is a systemic condition that may affect any dispose of arteries, such as those in the heart, brain, or periphery. just as atherosclerosis may lead to Coronary Heart Disease (CHD) peripheral atherosclerosis may lead to peripheral arterial disease (PAD). The primary symptom of PAD is intermittent claudication, that is, pain that appears with walking. This can become a potentially disabling condition if an individual cannot walk enough to ended daily activities. Intermittent claudication is defined as cramping or aching in the leg (usually calves) that increases with walking and improves with quietness Any of the lower extremity tubes may be involved, such as femoral or popliteal arteries, with the area of pain related to the tubes involved. Intermittent claudication pain leads to impairment of walking ability, and limits patients from performing personal, social, or occupational activities.

Pathophysiology

Since peripheral disease is individual expression of atherosclerosis, understanding the biology of atherosclerosis is useful.1 Atherosclerosis begins when exces plains of low-density lipoprotein (LDL) in the line penetrate the intima of the kindred vessels and become trapped. This LDL becomes oxidized, releasing anions. This oxidative stres releases proteins from the endothelium, which attracts monocytes using chemical and adhesion factors. As these and other composings of inflammation gather, they proliferate into fatty streaks and then "plaque" that occlude the lumen of the duct The atherosclerotic process continues to progres until there is narrowing of the utensil lumen and decreased blood roll on In peripheral vessels, claudication symptoms appear when the diameter of the utensil narrows by 50%.2 Vascular reactivity is also adversely affected in PAD. Prostacyclin and nitric oxide usually activate vascular relaxation. In PAD, these relaxation factors are reduc and constrictive factors so as endothelin increase. This imbalance of vascular reactivity also causes decreased vital fluid flow.2

When the decreased kindred flow through narrowed vessels is not adequate to fit the demand of the muscles during walking, ischemic or cramping pain is the resultant symptom.

Epidemiology

An estimated 12% of the adult population has PAD, with half of these demonstrating symptoms of intermittent claudication.3 The annual age adjusted incidence rates range from 01 -03% with a higher incidence among men 4 Of the risk factors for atherosclerosis, smoking and diabetes appear to be the chiefly important risk factors for unfolding of PAD. All forms of atherosclerosis are associated with increased morbidity and mortality.5 Mortality, as well as disability, is affected according to PAD, with a 60% survival rate after 10 years with PAD.6 Intermittent claudication has a stable course throughout 5 years, that is, it does not progres significantly.7

Treatment Goals

Treatment of patients with PAD is aimed at decreasing atherosclerosis risk factors, while treatment of the symptom of intermittent claudication (IC) is to increase functional walking distance. Modifying smoking and eating behaviors, treatment of hypertension and diabetes, and increasing physical activity are commited to decrease the risk of all atherosclerotic disease, including PAD. The 3 main treatment options for IC are exercise training, put drugs into therapy, and revascularization. Exercise training programs have been used favorably for 40 years, and demonstrate the importance of physical activity in the course of IC. Medications to improve family flow or decrease clotting have been tried with varying qualitys of success .8 Revascularization deeds may be performed if offspring flow is compromised enough to about symptoms of ischemic pain at ease or if tissue death has occurred9

Test and measures

Measurement tools to quantify disability and document progres may be divided into measures of impairment, functional measures, and specific exercise measures.

Impairment measures

There are many measures of impairment used to document atherosclerosis, nevertheless I will concentrate on 2 simple clinical measures that are useful for physical therapists in the course of exercise rehabilitation.

The Ankle/Brachial Index (ABI) is a measure of line pressure that can document kindred flow problems in the lower extremities. line pressures are measured both in the arm and the ankle, with the patient in a supine position for the pair measures. Brachial blood pressure is auscultated with the patient in the supine position. The ankle house pressure may be auscultated using the dorsalis pedis or posterior tibial is artery and the beat placed above the ankle, or using Doppler. The systolic ankle constraining force is divided by the brachial systolic urgency If both pressures are measured with the patient supine, and the sailing crafts normal, the ratio of ankle to brachial squeezings should be 1.0. If grow to the lower extremity is decreased, the ratio will be les than 10 An ABI